Opioids Prescribed at Discharge or Given During Emergency Department Visits Among Adults in the United States, 2016

May 31, 2019

Questions for Lead Author Anna Rui, Health Statistician, of “Opioids Prescribed at Discharge or Given During Emergency Department Visits Among Adults in the United States, 2016.”

Q: Why did you decide to focus on opioids prescribed at discharge or given during emergency department visits in the United States for this report?

AR:

Prescription opioid abuse and overdose continue to be critical public health issues. Opioid misuse, abuse, and overdose are affected by multiple factors including the number of people exposed. The Emergency Department (ED) is one setting where people could become exposed to opioids. In 2016, 27.5% of adult ED visits included opioids given in the ED, prescribed at ED discharge, or both (data not shown in report). The ED setting is where people frequently receive their first opioid treatment, after which patients with moderate to severe pain are often sent home with a prescription for an opioid, leaving them with the option of filling/not filling the prescription, or diverting filled prescriptions.

In the National Hospital Ambulatory Medical Care Survey (NHAMCS), information is collected on whether drugs are given during the ED visit, prescribed at discharge, or both.  However, in our published reports, the focus is on estimates of drugs and visits with drugs rather than how they are administered.  I wanted to assess visits with opioids prescribed at discharge separately to see how they compared with those given in the ED, in order to glean new information that has not previously been reported.  This could hopefully provide additional insight into patient populations visiting the ED who are exposed to opioids.


Q: How do rates of visits with opioids only given in the ED compare with opioids only prescribed at discharge and visits with both given and prescribed opioids?

AR: Generally, the rate of ED visits with opioids given during the visit was higher than the rate of ED visits with opioids prescribed at discharge.  Compared with the rate of ED visits with opioids prescribed at discharge, the rate where opioids were only given in the ED was higher among patients aged 45 and over and for both women and men.  Adults aged 18-44 were more likely to receive a prescription for an opioid at discharge compared with adults 45 and over.


Q: How did the data vary by emergency department visits where opioids were given, prescribed or both by primary diagnosis?

AR: The type of opioid administration among ED visits where opioids were given, prescribed, or both varied for certain selected diagnoses. For visits with a primary diagnosis of injury or trauma with opioids given or prescribed, the percentage with opioids only prescribed at discharge (40.7%) was higher than both the percentage of visits with opioids only given at the ED visit (26.3%) and visits with opioids both given and prescribed at discharge (32.7). Conversely, at visits for chest pain and abdominal pain with opioids given and/or prescribed, a higher percentage of opioids were only given at the ED visit. There was no variation across the types of opioid administration for back pain and extremity pain.


Q: Was there a specific finding in your report that surprised you?

AR:I was surprised at the high percentages of visits with opioids prescribed at discharge compared with those only given in the ED for certain diagnoses.  For example, among visits with a primary diagnosis of injury or trauma and where opioids were given or prescribed, a total of 73.4% included an opioid prescription at discharge.  Among visits primarily for extremity pain and where opioids were given or prescribed, 67.9% included an opioid prescription at discharge. Finally, among visits primarily for back pain in which opioids were given or prescribed, 64.5% included an opioid prescription at discharge. However I should also note that these estimates are based only on visits where the patient got opioids during the visit or at discharge.  For example, there are other ED visits made for injury where the patient did not get opioids at all, but we did not assess this in the report.


Q: Do you foresee the number of prescription opioids at emergency department visits increasing in the future?

AR: We do not make predictions about future data trends, but other research published by CDC for recent years showed stable or declining trends in the percentage of visits with opioids given in the ED, prescribed at discharge, or both.

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QuickStats: Percentage of Emergency Department Visits Made by Patients with Chronic Kidney Disease Among Persons Aged 18 Years or Older, by Race/Ethnicity and Sex

January 11, 2019

During 2015–2016, 3.5% of adult visits to the emergency department were made by those with chronic kidney disease.

A higher percentage of visits were made by men with chronic kidney disease than women (4.1% compared with 2.7%).

The same pattern was observed for non-Hispanic black men (5.0%) and women (2.4%).

Although the pattern was similar, there was no statistically significant difference in emergency department visits by sex for Hispanic and non-Hispanic white adults.

SOURCE: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2015–2016.

https://www.cdc.gov/mmwr/volumes/68/wr/mm6801a7.htm


National Hospital Care Survey Demonstration Projects: Pneumonia Inpatient Hospitalizations and Emergency Department Visits

August 24, 2018

Sonja Williams, M.P.H., NCHS Statistician

Questions for Sonja Williams, M.P.H. and Lead Author of “National Hospital Care Survey Demonstration Projects: Pneumonia Inpatient Hospitalizations and Emergency Department Visits

Q: What is a demonstration project as mentioned in the title of your new study?

SW: A demonstration project is a report that exhibits the potential power of an up and coming national survey.  The National Hospital Care Survey is a survey collecting data from a nationally representative sample of hospitals across the United States. This survey data will allow linkage across settings and to outside data sources. Currently, with only a small number of the sampled hospitals reporting, we are not able to make national estimates. This project is an opportunity to tell researchers that although the data are not nationally representative yet, there are great insights that can be gleaned from the data we currently have.


Q: Why did you produce this report if the statistical results are not nationally representative?

SW: It is the dramatic potential of the National Hospital Care Survey data that motivated me to write this report. I want the U.S. Public Health Community to have information that will help them in their important work throughout America, and this survey could provide that. Although not yet nationally representative, we have millions of records that can demonstrate the power of the survey and still give us insight into what is happening in hospitals in the United States. This report also gives us an opportunity to demonstrate the ability to link to outside sources, such as the National Death Index, and examine what happens to patients after they leave the hospital.


Q: What type of trend data do you have on pneumonia hospitalizations and emergency room visits?

SW: We have extensive trend data from a number of surveys at the National Center for Health Statistics. For example, the National Hospital Discharge Survey, which is the predecessor to the National Hospital Care Survey, has trend data on pneumonia hospitalizations dating from the 1970s all the way to 2010—the last year the National Hospital Discharge Survey was fielded. For emergency room visits, we have trend data dating from 1992 to 2015 through the National Hospital Ambulatory Medical Care Survey. Once nationally representative, the National Hospital Care Survey will be able to produce trend data and possibly create trends for linked data.    


Q: Was there a finding in your new study that really surprised you?

SW: One finding that surprised me was that most pneumonia patients who died within 30 days after their discharge from the hospital, died of something other than pneumonia.

We were able to link our data to the National Death Index (NDI) and examine 30-, 60-, and 90 day- mortality along with looking at cause of death and average age of death after pneumonia hospitalizations. It was interesting to see that most patients lived past 90 days post-discharge, but of those who died, the number one cause of death was malignant neoplasm of an unspecified part of the bronchus or lung. Pneumonia was only the underlying cause of death for 5% of the patients who were hospitalized for pneumonia. Currently, with only a small number of the sampled hospitals reporting, we are not able to make national estimates.


Q: What differences or similarities did you see between or among various demographic groups in this analysis?

SW: There were some interesting differences among demographic groups. For example, there were several age distribution differences.

Among the records in our survey, most hospitalizations for pneumonia were aged 65 and over, while most of those being seen in the emergency department were under age 15. For those inpatients that stayed in the ICU, their average length of stay increased by 50% overall. Also, the gap between the average length of stay with and without time spent in the ICU, seemed to be the largest among those under age 15. For those under 15, their average length of stay was 3.1 days, while for the same age group—among those who stayed in the ICU—their average length of stay was 7.7 days. This is nearly a 5-day difference. The gap between ICU and non-ICU involved hospitalizations for other age groups did not have such a wide difference. Currently, with only a small number of the sampled hospitals reporting, we are not able to make national estimates.


Q: What would you say is the take-home message of this report?

SW: I think the real take-home message of this report is that once nationally representative, the National Hospital Care Survey will present an opportunity to look at hospital utilization—along with hospital care—across settings in the United States. The ability to link to outside sources of data, demonstrated in our current linkage to the National Death Index, will allow researchers to explore underlying cause of death and mortality details not previously available. This ability to link will also allow researchers to explore how surrounding social and economic factors can contribute to outcomes of hospital stays through linkage to other data sources such as U.S Census Bureau data. Also, the ability to look at key items of interest in greater detail, such as discharge status, and tracking ICU-involved hospitalizations, will give us a unique view into the care being conducted in hospitals across the United States.


Identification of Substance-involved Emergency Department Visits Using Data From the National Hospital Care Survey

August 20, 2018

Questions for Amy M. Brown, Health Statistician and Lead Author of “Identification of Substance-involved Emergency Department Visits Using Data From the National Hospital Care Survey

Q: Why is this National Health Statistics Report (NHSR) important?

AB: The use of substances containing drugs or alcohol continues to be an important national health concern.  According to data from the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2011, an estimated 2.5 million emergency department (ED) visits resulted from medical emergencies involving drug misuse or abuse.  This paper presents two approaches (algorithms) to identify substance-involved ED visits using administrative claims data submitted to the National Hospital Care Survey. The ability to identify substance-involved ED visits will allow the National Center for Health Statistics (NCHS) and researchers to track and characterize these visits, including services provided, demographics, and co-morbidities.  


Q: What are the differences between these algorithms?  

AB: The two algorithms are termed ‘general’ and ‘enhanced.’ Both use selected diagnoses and external cause of injury codes. The general algorithm can be used to monitor trends in the number of ED patients with any record of substance use (either recent or past history). The enhanced algorithm adds codes for substance use-related symptoms and procedures and was designed to meet a more specific case definition to identify ED visits involving recent substance use that was related to the reason for visit.


Q: Which substances can be identified by the algorithms? 

AB: The general and enhanced algorithms can be used to identify 10 substance categories:  alcohol (under age 21); antidepressants; antipsychotics; benzodiazepines or sedatives; cannabinoids; cocaine; hallucinogens; heroin; opiates or opioids; and pharmaceutical central nervous system stimulants. 


Q: What was found when these algorithms were applied to survey data?

AB: For demonstration purposes, both algorithms were applied to unweighted data from the 2013 National Hospital Care Survey. Overall, the general algorithm identified 81% more ED visits involving at least one of the priority substance categories compared with the enhanced algorithm.  However, the relative percent difference in the number of ED visits identified between the general and enhanced algorithms varied widely depending on the type of substance involved, ranging from 28% for antidepressants to 120% for cannabinoids.

The percent distributions of patient sex, age, and expected source of payment across all substances were similar between the general and enhanced algorithms.  In contrast, there were differences in discharge status distributions between both algorithms across all substances.


Q: What is the take home message of this report?

AB: Two algorithms are described that search for selected standard medical codes in administrative claims to identify ED visits involving the use of selected substances. NCHS plans to continue refining the algorithms to incorporate additional data elements available in the growing volume of submitted electronic health record (EHR) data, such as clinical notes capturing patient statements regarding events leading up to an ED visit, positive blood or urine tests for specific substances, and types of medication administered or prescribed during the encounter. Once refined and formally validated to ensure accuracy, they can be used with National Hospital Care Survey data to eventually generate national estimates of substance-involved ED visits.


Emergency Department Visits by Patients aged 45 and over with Diabetes: United States, 2015

February 8, 2018

Questions for Pinyao Rui, Statistician and Author of, “Emergency Department Visits by Patients aged 45 and over with Diabetes: United States, 2015.”

Q: Why did you decide to examine emergency department (ED) visits made by patients aged 45 years older with diabetes?

PR: We decided to examine emergency department visits made by patients aged 45 years and older because we wanted to focus on visits made by older patients who are at higher risk of developing or having diabetes and who comprise a majority of all diabetes cases in the U.S.  Additionally, we wanted to use more recent data not currently available in the literature to examine characteristics of an ED visit for a condition that is projected to rise and contribute to increasing burden of medical care systems.


Q: How did the rate of emergency department visits by patients aged 45 and over with diabetes change with age?

PR: The rate of emergency department visits by patients aged 45 and over increased with age. The rate increased from 69 per 1,000 persons for those aged 45-64 years and more than doubled to 164 per 1,000 persons for those aged 75 years and over.


Q: Were there differences in the percentage of visits that ended in inpatient hospital admission by diabetes status?

PR: Yes, the percentage of ED visits with diabetes that ended in inpatient hospital admission was significantly higher than the percentage of ED visits without diabetes among visits made by patients aged 45-64 and 65 and over.


Q: Are there any findings that surprised you from this report?

PR: One finding from the report that surprised me was that among ED visits made by 45-64 year olds, a higher proportion of diabetes visits were paid by Medicare compared with visits made by patients without diabetes (24% versus 14%).


Q: What is the take home message in this report?

PR: I think the take home message is that the percentage of ED visits by older patients with diabetes reported in the medical record has been increasing in recent years with the highest proportion observed in patients aged 65-74 (32% in 2015).


QuickStats: Percentage of Emergency Department Visits for Acute Viral Upper Respiratory Tract Infection That Had an Antimicrobial Ordered or Prescribed, by Metropolitan Statistical Area — United States, 2008–2015

January 29, 2018

From 2008–2011 to 2012–2015, the percentage of visits for acute viral upper respiratory tract infection that had an antimicrobial ordered or prescribed decreased from 37.1% to 25.5% among emergency departments (EDs) located in nonmetropolitan statistical areas, but this decline was not seen among EDs in metropolitan statistical areas.

In 2008–2011, the percentage was higher among nonmetropolitan EDs than metropolitan EDs, but there was no difference in 2012–2015.

Source: National Hospital Ambulatory Medical Care Survey, 2008–2015
https://www.cdc.gov/mmwr/volumes/67/wr/mm6703a7.htm


Fact or Fiction: Is the Average Wait Time to See a Medical Professional in the Emergency Room Less Than an Hour?

November 9, 2017

Source: National Hospital Ambulatory Medical Care Survey

https://www.cdc.gov/nchs/data/nhamcs/web_tables/2014_ed_web_tables.pdf

https://www.cdc.gov/nchs/pressroom/videos/2017/november2017/FOFNovember2017.htm